Hospitalization Following Discharge From a Skilled Nursing Facility (HFS)

Assesses the rate of discharges from a skilled nursing facility (SNF) that were followed by an unplanned acute inpatient or observation stay within 30 and 60 days after discharge among Medicare (65 and older) health plan members. As well as reporting observed rates, NCQA also specifies that plans report an expected count of unplanned acute hospitalizations, predicted using members’ prior and current health, among other factors. The observed event count and the expected event count are used to calculate a calibrated observed-to-expected (O/E) ratio that assesses whether plans had more, the same or fewer acute hospitalizations than predicted by their case mix, while accounting for incremental improvements across all plans over time. An O/E ratio below 1 indicates better-than-average performance and an O/E ratio above 1 indicates worse-than-average performance.

Why It Matters

Skilled nursing facilities provide extended rehabilitative care beyond the care provided during an acute hospitalization. Medicare beneficiaries requiring SNF services are among the most vulnerable, and a high rate of patient admissions post-SNF discharge may indicate inadequate quality of care in the hospital, the SNF, or a lack of appropriate care coordination. Unplanned hospitalizations after discharge from a SNF are associated with negative outcomes, including increased mortality, for Medicare beneficiaries. Unplanned admissions can be prevented by standardizing and improving care coordination and increasing support after SNF discharge.^1,2

Historical Results – National Averages

Performance results for this measure are currently unavailable. Visit our Quality Compass page to explore data licensing options and gain access to detailed performance results for this measure.